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03/25/2019 10 : 12 #4101 P. 001/001
<br /> 10t77ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@evorettwa.gov 1 wwwv.averettwa.gov/permits
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<br /> PROJECT ADDRESS: 1421 W MUKILTEO BLVD BUILDING AREA: sq ft
<br /> PROJECT TYPE: ❑ NEW CONSTRUCTION El ADDITION ❑TENANT IMPROVMENT LI REMODEL
<br /> BUILDING USE: 0 SFR ❑TOWNHOUSE ❑ DUPLEX LI ADU LI MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL
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<br /> CONTRACT PRICE OF WORK:$ 4600 (ASSOCIATED BUILDING PERMIT($(if applicable):
<br /> DESCRIBE SCOPE OF WORK:
<br /> REPLACE SERVICE PANEL. NEW CIRCUITS FOR RANGE & FRIDGE
<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE:(SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? ❑ NO El YES-Select Scope: Service 0 Feeder ✓❑Circuits-#:3 El Complete Re-wire _
<br /> LOW VOLTAGE WORK? ❑ NO ❑YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom ❑Thermostat ❑Audio ❑ Secure Access El Security System
<br /> ❑ Fire Alarm-installations under this permit only include electrical wiring rough-in of the system-An additional
<br /> Fire Alarm Permit is required for review of device location and installation approval.
<br /> ❑ Other(List Al!):
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<br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL.CARE FACILITIES: NO ❑YES--See Below&Pg-2
<br /> By checking this box,I am stating that I have read and understand ail of WAC 2913#3B-900,selected the specific reason on page 2
<br /> of this application(see next page),AND Plan Review is NOT required because I meet all of the following sub sections that do not
<br /> See Page 2 require Plan Review.
<br /> ARE YOUAN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: QNO 1YES-See Below&Pg.3
<br /> HL 1 Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease
<br /> without the proper electrical licensing and certification, or exemption. By chocking this box, I am stating that I have completed and
<br /> See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement.
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<br /> OWNER NAME: CAROL FORSBERG TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 1421 W MUKILTEO BLVD
<br /> air EVERETT STATE WA zrr,98203
<br /> OWNER PHONE:425-258.2015 OWNER EMAIL:
<br /> CONTRACTOR NAME: EYLANDER SALES & SERVICE
<br /> CONTRACTOR ADDRESS: STREET3601 EVERETT AVE
<br /> Cir EVERETT STATE WA ZIP 98201
<br /> CONTRACTOR PHONE:425.259.2161 (CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED):EYLANSS142LP CITY OF EVERETT BUSINESS LIC.#(REQUIRED):016363
<br /> PRIMARY CONTACT: ❑OWNER ❑✓CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME:JOHN I V!E� CONTACT PHONE:425.231.2275
<br /> CONTACT EMAIL:
<br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correcL AI provisions of laws and ordinances governing this
<br /> type of work will be completed whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state or
<br /> local law regulating construction or the performance of construction. That I am authorized by the owner of this property to perforin the work for which application is made and I
<br /> comply with the-tate Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> ✓ PERMIT#:
<br /> 5/5/4rE t) -2-) (
<br /> 0 piuthorized Agent Signature {Revised 7/77/2079) Page 1-Application
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